The Development of MML (Medical Markup Language) Version 3.0 as a Medical Document Exchange Format for HL7 Messages

Medical Markup Language (MML), as a set of standards, has been developed over the last 8 years to allow the exchange of medical data between different medical information providers. MML Version 2.21 used XML as a metalanguage and was announced in 1999. In 2001, MML was updated to Version 2.3, which contained 12 modules. The latest version—Version 3.0—is based on the HL7 Clinical Document Architecture (CDA). During the development of this new version, the structure of MML Version 2.3 was analyzed, subdivided into several categories, and redefined so the information defined in MML could be described in HL7 CDA Level One. As a result of this development, it has become possible to exchange MML Version 3.0 medical documents via HL7 messages.     

基于CDA的临床数据中心文档构建及XDS共享模式研究

临床文档共享是整合医院内部异构系统、构建临床数据中心和实现信息集成的重要手段。结合HL7 CDA文档架构和国家相关数据标准以及规范,对临床文档的结构和语义进行标准化和本地化定义,支持异构系统之间临床文档的互操作,并基于1HEXDS文档共享模式进一步实现跨系统临床文档交互,提高临床质量。最后对结构化临床文档的数据可用性以及科研检索、数据安全性和保密性等进行初步讨论。     

基于HL7CDAD门诊电子病历的设计与实现

探讨基于HL7CDA门诊电子病历的设计与实现方法,参考HL7CDA标准,对门诊病历信息的结构与语义进行定义,包括：建立门诊电子病历的CDA文档。用于门诊病历内容的表达;建立基于此CDA的样式表文件。便于其信息浏览。实践证明。以HL7CDA标准为基础,规范了门诊电子病历信息的结构与语义,为门诊病历信息的共享与交换提供了一个可行的方法。     

建设基于XML技术电子病历系统的核心价值

介绍了电子病历的基本问题和HL7 CDA临床文档标准;提出XML电子病历编辑器是完成数据类型复杂医疗文档的重要工具;认为在医院建设基于XML技术电子病历系统的核心价值体现在方便快捷的医疗信息采集、医疗质量实时监控、医疗管理决策支持和医疗科研应用等方面。     

基于HL7 v3 CDA的可交换影像结果报告设计与实现

探讨了基于HL7 v3 CDA R2标准的影像结果报告的设计与实现方法。根据卫生部颁布的电子病历基本数据元、数据集,提出一套基于HL7 v3 CDA R2,面向文档,针对数据的本地化临床影像结果报告CDA文档模板,包括对影像报告的结构和语义进行定义,影像结果临床描述内容的表达,关键术语与模板的绑定,针对该CDA模板的自定义样式表文件,为影像结果信息的互操作在语法和语义2个层次上提供了一个可行的方法。     

HL7 Clinical Document Architecture,Release 2

Clinical Document Architecture, Release One (CDA R1), became an American National Standards Institute (ANSI)–approved HL7 Standard in November 2000, representing the first specification derived from the Health Level 7 (HL7) Reference Information Model (RIM). CDA, Release Two (CDA R2), became an ANSI-approved HL7 Standard in May 2005 and is the subject of this article, where the focus is primarily on how the standard has evolved since CDA R1, particularly in the area of semantic representation of clinical events. CDA is a document markup standard that specifies the structure and semantics of a clinical document (such as a discharge summary or progress note) for the purpose of exchange. A CDA document is a defined and complete information object that can include text, images, sounds, and other multimedia content. It can be transferred within a message and can exist independently, outside the transferring message. CDA documents are encoded in Extensible Markup Language (XML), and they derive their machine processable meaning from the RIM, coupled with terminology. The CDA R2 model is richly expressive, enabling the formal representation of clinical statements (such as observations, medication administrations, and adverse events) such that they can be interpreted and acted upon by a computer. On the other hand, CDA R2 offers a low bar for adoption, providing a mechanism for simply wrapping a non-XML document with the CDA header or for creating a document with a structured header and sections containing only narrative content. The intent is to facilitate widespread adoption, while providing a mechanism for incremental semantic interoperability.     

A Software Tool for Removing Patient Identifying Information from Clinical Documents

We created a software tool that accurately removes all patient identifying information from various kinds of clinical data documents, including laboratory and narrative reports. We created the Medical De-identification System (MeDS), a software tool that de-identifies clinical documents, and performed 2 evaluations. Our first evaluation used 2,400 Health Level Seven (HL7) messages from 10 different HL7 message producers. After modifying the software based on the results of this first evaluation, we performed a second evaluation using 7,190 pathology report HL7 messages. We compared the results of MeDS de-identification process to a gold standard of human review to find identifying strings. For both evaluations, we calculated the number of successful scrubs, missed identifiers, and over-scrubs committed by MeDS and evaluated the readability and interpretability of the scrubbed messages. We categorized all missed identifiers into 3 groups: (1) complete HIPAA-specified identifiers, (2) HIPAA-specified identifier fragments, (3) non-HIPAA–specified identifiers (such as provider names and addresses). In the results of the first-pass evaluation, MeDS scrubbed 11,273 (99.06%) of the 11,380 HIPAA-specified identifiers and 38,095 (98.26%) of the 38,768 non-HIPAA–specified identifiers. In our second evaluation (status postmodification to the software), MeDS scrubbed 79,993 (99.47%) of the 80,418 HIPAA-specified identifiers and 12,689 (96.93%) of the 13,091 non-HIPAA–specified identifiers. Approximately 95% of scrubbed messages were both readable and interpretable. We conclude that MeDS successfully de-identified a wide range of medical documents from numerous sources and creates scrubbed reports that retain their interpretability, thereby maintaining their usefulness for research.     

基于CDA标准的临床数据中心研究和应用

临床数据共享是整合医院内部异构系统、构建以电子病历（Electronic Medical Record,EMR）为核心的统一临床数据中心的重要手段.基于CDA标准的信息采集、传输和存储是实现临床医疗文档跨系统交互、提高临床质量的技术保障.结合CDA文档架构,对临床文档的结构和语义进行了标准化和本地化定义,实现了数据的结构化存储、异构系统间的通信和数据交换.     

医疗卫生信息交换中XML验证方法研究

医疗卫生信息交换中，必须确保不同医疗机构间信息交换的标准性、一致性、完整性、语义性。才有可能实现跨院基于EsB架构的互联共享。针对这一需求，结合目前信息交换中普遍采用的xML文件格式，在借鉴HL7、cDA等国际标准实践经验的基础上，比较分析了Schema、Schematron、CAM等几种验证方法优缺点，与我国卫生信息标准相结合，提出了一套适合中国当前国情的XML验证方法。     

基于HL7标准的XML语言在口腔正畸电子病历中的运用

目的基于口腔专科医院信息化建设需要,探讨基于HL7标准的XML语言在口腔正畸电子病历数据结构以及录入、交换、集成、存储、安全等方面的应用。方法在新一代口腔专科医院信息化管理系统上,采用面向对象技术,基于Windows2000/XP平台,以XML语言和HL7标准为具体手段,构建口腔正畸电子病历功能模块和网络运行构架,开发出面向正畸临床的网络化电子病历管理系统。结果基于HL7标准和XML语言的口腔正畸电子病例可准确、方便地进行临床资料的信息化管理,解决了正畸专科电子病历的结构、操作、数据交换和安全等问题。结论本研究为口腔正畸医师和医疗管理者提供了一种高度信息化的正畸临床资料管理模式,提高了口腔正畸专科医疗质量控制手段和管理效率。     

基于HL7 CDA标准和XML技术在电子病历系统中的应用

在对电子病历系统互通性的分析基础上。简单论述了电子病历相关的HL7 CDA标准的主要内容、CDA标准与HL7 V3标准的相关性以及采用XML技术进行医疗文档描述的优点。最后介绍了CDA标准在电子病历系统中的应用举例。     

基于数据共享的中医电子病历研究

中医信息化水平的迅速发展促使中医电子病历数据共享成为迫切需要。重点论述中医电子病历的特色,研究基于HL7 CDA标准构建中医电子病历共享文档的方法和流程,最后讨论电子病历相关安全问题及解决途径,为中医电子病历数据共享进程的推进提供参考。     

Comparison of a semi-automatic annotation tool and a natural language processing application for the generation of clinical statement entries

Background and objective Electronic medical records with encoded entries should enhance the semantic interoperability of document exchange. However, it remains a challenge to encode the narrative concept and to transform the coded concepts into a standard entry-level document. This study aimed to use a novel approach for the generation of entry-level interoperable clinical documents.Methods Using HL7 clinical document architecture (CDA) as the example, we developed three pipelines to generate entry-level CDA documents. The first approach was a semi-automatic annotation pipeline (SAAP), the second was a natural language processing (NLP) pipeline, and the third merged the above two pipelines. We randomly selected 50 test documents from the i2b2 corpora to evaluate the performance of the three pipelines.Results The 50 randomly selected test documents contained 9365 words, including 588 Observation terms and 123 Procedure terms. For the Observation terms, the merged pipeline had a significantly higher F-measure than the NLP pipeline (0.89 vs 0.80, p<0.0001), but a similar F-measure to that of the SAAP (0.89 vs 0.87). For the Procedure terms, the F-measure was not significantly different among the three pipelines.Conclusions The combination of a semi-automatic annotation approach and the NLP application seems to be a solution for generating entry-level interoperable clinical documents.     

Enhancement of MML Medical Data Exchange Standard for a Localized Chinese Version

Medical Markup Language (MML) is a standard for the exchange of medical data among different medical institutions. It was developed in Japan in 1995. Since version 2.21, MML has used eXtensible Markup Language (XML) as a meta-language. The latest version, 3.0, conforms to HL7 Clinical Document Architecture (CDA) and contains 14 modules and 36 data definition tables. In China, a standard which structures entire medical records in XML does not yet exist. Taking advantage of MML's flexibility, we created a localized Chinese version based on MML 3.0. Parts of the original specifications have been enhanced; these include a newly developed health insurance information module and 12 additional or redefined data definition tables. The Chinese version takes local needs into account and now makes it possible to exchange medical data among Chinese medical institutions.     

支持临床路径的电子病历系统开发设计

结合临床路径实施过程,重新整合支持临床路径的电子病历系统流程,研究基于HL7 CDA的电子病历数据结构化和标准化原则以及混合关系数据库和XML的存储模式,提出一种支持临床路径的电子病历系统解决方案,并通过原型系统进行实践.     

基于HL7CDA的异构医疗信息系统集成技术研究

医疗卫生信息系统的应用和多系统共存已成为我国医疗服务发展的必然趋势.然而,院内各医疗信息系统很多都是相互独立的,传统的系统集成方案大都基于关系型数据库的对接,可扩展性、互操作性、安全性都较差.为实现各系统的整合和信息数据的实时共享与充分利用,提出一种基于HL7 CDA（Health Level Seven,Clinical DocumentArchitecture）标准的医疗信息系统集成方案.以CDA文档为基础,设计基于卫生部数据集标准的CDA模板,采用WebService方式实现异构信息系统之间的信息共享和业务联动.     

医疗术语编码方案与可交换信息结构绑定方法探讨

探讨医疗术语编码方案与可交换信息结构绑定的一种方法。通过将卫生部颁布的基本医疗数据集（BDS）中的相关数据元与HL7 v3 CDA R2体系结构相结合，实现用一种特定的方式捕获、显示临床医疗数据，以标准化、无歧义的数据格式处理临床描述。     

中日标准化电子临床路径的设计与实现

介绍标准化临床路径的概念,分别阐述日本、中国标准化临床路径研究与设计情况,利用HL7标准、CDA技术实现标准化数据交换,指出标准化电子临床路径会在地域间协同医疗中发挥不可忽视的作用。     

面向互认共享的医学影像结果报告结构化模板的构建

在分析梳理面向共享的医学影像结果报告业务流程的基础上,借鉴HL7 CDA R2架构,基于我国卫生信息共享文档编制规范,构建了医学影像结果报告的结构化模板,并与卫生信息数据元目录进行了映射。其中文档头包括主题数据和管理数据,文档体分为临床信息、成像设备信息及过程描述、检查结果信息3个章节及若干条目。